Diaphragmatic Hernias in Trauma

Transcription

1 Diaphragmatic Hernias in Trauma ONAONA GURNEY, PGY4 SUNY DOWNSTATE DEPARTMENT OF SURGERY AUGUST 28 TH 2015

2 Case Presentation 61M restrained driver in MVA, transferred from Brookdale Hospital Airbag deployment, prolonged extrication

3 Physical Survey ABC intact, GCS 15 Afebrile / %RA A&Ox3 s1s2 present, no mrg Decreased BS on L s/nt/nd Decreased motor strength on LLE 2/2 pain, sensation intact, femoral/dp 2+ BL, no gross deformities FAST negative

4 Brief History PMH: DM, CAD s/p stents x2 (7yrs prior) MEDS: Metformin, ASA (stopped 7d prior) NKDA PSH: Lap appendectomy & prostatectomy SH: social EtOH, denies tobacco/ivda FH: non-contributory

5 Labs & Imaging 10.5>14.5/45< /4.1/100/25/15/1.03< /4.2/109/60/ /24.5<1.1

6 CT Chest

7 Operation Performed Laparoscopic repair of traumatic left sided diaphragmatic hernia with placement of L sided chest tube

8 Hospital Course POD 1: Chest tube removed POD 2: Episode of a. fib w/rvr, elevated trop POD 12: Orthopedic repair of pelvic fx POD 1/13: Extubated in SICU, NSTEMI POD 5/17: Downgraded to floor Currently in acute rehab recovering!

9 QUESTIONS????

10 Diaphragmatic Hernias Hernia: Derived from latin word for rupture

11 First described in 1541 by Sennertus 1 Pare described first organ strangulation as consequence of TDH History First successful repair by Riolfi in

12 Diaphragmatic Rupture Tear of musculature secondary to trauma Resultant herniation of abdominal contents into thoracic cavity Incidence 0.8-5% 3 75% secondary to blunt trauma

13 Anatomy

14 Characteristics Majority present on the left Organs most commonly herniated 2 Stomach Spleen Small/large bowel, mesentery

15 Presentation Physical Exam Decreased breath sounds & SOB Chest & abdominal pain Bowel sounds auscultated in chest Scaphoid abdomen Shoulder pain

16 Diagnosis HIGH INDEX OF SUSPICION!! Physical Exam findings CXR CT Scan FAST UGIS, Barium enema, MRI Operative exploration

17 Chest X-Ray

18 CT Scan Sensitivity close to 95% 6 Without herniation sensitivity poor Aides w/dx of other injuries

19 Operative Exploration Exploratory Laparotomy Laparoscopy/Thoracoscopy Thoracotomy

20 Treatment ABC s, identify, stabilize and treat other life threatening injuries OR for definitive repair recommended approach to diaphragmatic injury: midline laparotomy 3

21 Surgical Goals Complete reduction of hernia contents Repair of diaphragmatic injury, preventing recurrence

22 Laparoscopic Repair Position in reverse Trendelenburg with R side down Prepare for possibility of emergent chest tube Use of 30 degree scope Port placement Reduction of hernia Irrigation of chest Non-absorbable suture repair

23 Port Placement

24

25 Non-absorbable suture Technical Repair

26 Mesh Use Not advocated for acute injury If defect cannot be closed primarily, in the setting of bowel contamination, biologic mesh is a feasible option

27 Summary Diagnosis requires high index of suspicion CXR/CT scan are most common modality of diagnosis Diagnostic/therapeutic laparoscopy in hemodynamically patient becoming standard Exploratory laparotomy still considered standard of care Primary repair with non-absorbable suture Use of biologic mesh in acute setting feasible option when primary repair not possible and bowel contamination is present

28 Thank You

29 References 1: Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med Nov. 22(7): : Meyers BF, McCabe CJ Traumatic diaphragmatic hernia. Ann Surg 1993;218: : Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg Jun. 33(6): : Hanna W.C., Ferri L.E., Fata P., et al: The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008; 85: pp : Carter B.N., Guiseffi J., and Felson B.: Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther 1951; 65: pp. 56 6: Marts B., Durham R., Shapiro M., et al: Computed tomography in the diagnosis of blunt thoracic injury. Am J Surg 1994; 168: pp